Dr. Amit Kr Singh MBBS, MS General surgery
Kolkata West Bengal

General Anaesthesia :
The patient should be under GA.
Position the patient in the supine position.
 Availability of the following instruments should be checked :
Access instruments: Blade 11, Veress needle, two 10 mm ports, two 5 mm ports.
Optical instruments: 10 mm telescope, camera, light cable.
Operating instruments: Maryland, Traumatic grasper, semi traumatic grasper, endoclips, Curved endoscissor, Vicryl suture, endobag.

Energy instruments: Harmonic, hook connected with monopolar.
Check the function of the monitor, Insufflator, light source, amount of gas cylinder, harmonic setting frequency between 3-5, and check the monopolar function for cutting and coagulation.
Patient and surgeon Positioning :
Table height should be adjusted to the surgeon height (0.49 X surgeon height).
The patient should be prepped form the nipples to the mid-thighs: patient draping and cable arrangement.
The surgeon should stand on the left side of the patient. The monitor at the right side of the patient,1st assistant, should be on the left side of the surgeon and the 2nd assistant at the right side of the patient.
The monitor, target organ, and surgeon should be aligned in coaxial alignment.
The monitor should be at 15 degrees below the surgeon's eyes and 5 times of its diagonal diameter away from the surgeon.
Access and Insufflation:
Umbilicus to hold With Allys Forceps, then using blade 11, 3 mm incision to be made at the inferior crease of the umbilicus.
Size 10 Veress needle insertion: start with checking the veress needle function and patency by flushing it with NS and hearing two clicks of the valve.
 The length of the needle which should be inserted should be 4cm + abdominal wall thickness. Veress Needle should be held as a dart at 45 degrees, left the abdominal wall in a way that veress needle should be perpendicular to it and pointed toward the anus. Will feel two areas of resistance, should be intrabdominal after you passed the 2nd area.
Check the position of the Veress needle in three ways:
Flush the needle with NS, which should go easily.
Aspirate, nothing should come.

Hanging drop test: drops of NS are placed at the cannula of the needle, should sink when the lower abdominal wall is lifted.

5. Qudrimanometric 40 liters Insufflator to be on, the following setting should be applied:
a. Set pressure 12 and flow 1 L / min.
6. The gas tube should be flushed with CO2 before attaching it to the veress needle.
7. The gas tube to be attached to the veress needle and start insufflation, making sure that the abdomen is tympanic and distended equally in all quadrants. Insufflator's parameters should be observed during insufflation.
 8. Once the actual pressure reaches the set pressure of 12 mmHg, the Veress needle will be removed.
9. At the same umbilical, inferior crease, Using a 10 mm cannula, the area is marked for the incision, then the incision increased to 10 mm, smiley incision.
10. The vetelinointestinal tract is opened and dilated with artery forceps.
11. 10mm port is inserted through the tract and attached to the gas tube.
12. 30 degrees Camera to be adjusted in terms of white balance, and focus.
13. Camera to be inserted and check for any bleeding, adhesion or bowel injury.

Working ports insertion :

Based on the baseball diamond concept, working ports sites are determined and inserted under direct visualization as follows:
10 mm port at the epigastric area at the line between xiphisternum and umbilicus. This port should be inserted left to the falciform ligament but piercing the membranous part and should come out right to it.
5 mm port at the right midclavicular line, around 2 cm below the costal margin.
5 mm port at the right mid-axillary line, around 5-8 cm below the costal margin.

Surgical steps:

Position the patient in the left lateral, head up.
Through the lateral 5mm port, Using the traumatic grasper, the fundus of the gallbladders should be retracted upward and toward the right shoulder of the patient.
The gall bladder is retracted anteromedially, With the help of the grasper the Hartmans pouch exposed, all adhesions are released with blunt dissection or Harmonic use.
The Gallbladder infundibulum is retracted toward the left shoulder so the anterior peritoneum is exposed.
Making sure that we are above the Rouviere’s Sulcus, dissection to be started at the anterior peritoneum at the Hartmans pouch level using the harmonic.
Then the infundibulum is retracted to the right side, and anterior lateral posterior peritoneum is exposed and dissected.
By this time, a window is created below the infundibulum connecting the anterior and posterior openings.
The critical view of safety (cystic duct, CHD, and the edge of the liver) is viewed, Cystic duct is identified, dissected, and isolated from the artery. Always avoid over traction, to prevent CBD injury.
Using Vicryl suture with Mishra's knot, the cystic duct is ligated near the CBD. Moreover, clips are applied at the distal end of the duct. Using the scissor, the cystic duct is cut between the clips and the knot.
The cystic artery is identified and clipped using the end clips by applying 2 clips proximally and one clip distally. The artery cut using scissors.
Using the Harmonic, the gallbladder is dissected from its bed in the liver surface by cutting the anterior and posterior peritoneum.
Dissection continued till the fundus of the gallbladder, till it is detached from the liver.

The gallbladder bed is inspected for any bleeding and should be controlled by using fulguration by monopolar (using hook).
Using endobag, the gallbladder is retrieved through the epigastric port.
Ports removal and closure:
Under direct vision, 5 mm ports and epigastric port are removed.
Gas insufflation is stopped, the abdomen is deflated, The umbilicus port is removed, facia is closed using Vicryl 0.
All Skin incisions are closed using Rapide Vicryl or staplers.

Elaborated Steps:

Position the patient in the supine position with both arms tucked.

Administer general anesthesia.

Place a Foley catheter to empty the bladder.

Preoperative antibiotics are administered.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 2-3 additional trocars as required.

Identify the gallbladder, liver, common bile duct, cystic duct, and cystic artery.

Use the hook cautery to dissect the cystic artery.

Clip and divide the cystic artery.

Dissect the cystic duct.

Clip and divide the cystic duct.

Use the hook cautery or harmonic scalpel to dissect the gallbladder from the liver bed.

Use a grasper to retract the gallbladder.

Use the hook cautery or harmonic scalpel to dissect the gallbladder from the liver bed.

Use a grasper to retract the gallbladder.

Continue dissection until the gallbladder is free from the liver bed.

Use a retrieval bag to extract the gallbladder.

Inspect the cystic duct and cystic artery for hemostasis.

Remove the trocars.

Deflate the abdomen.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid heavy lifting for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.